Medical education is transforming. Currently, manikin-based simulation is the gold standard used for clinical training, yet, despite being effective, it is quite resource-intensive. Manikin-based simulation requires dedicated space, equipment, and personnel to run simulation sessions for medical trainees [1,2]. Often, the educational facility will need simulation specialists to oversee the simulation and medical facilitators to debrief participants to support learning.
Virtual reality (VR) is emerging as a new, flexible method of delivering simulation sessions that allows for educational standardization. Central to VR is the concept of immersion, which is defined as the perception and belief of being present in a simulated world [3]. VR is a computer-generated world that involves immersion and sensory feedback. VR-based medical simulation offers benefits for both medical learners and educators by providing various means of delivering learning content [3-5]. VR is standardized, accessible, and can have assessment metrics and feedback built into the VR environment. Moreover, the medical trainee can go through the VR environment remotely, at any location or time of day. VR allows learners to make mistakes safely and then learn through deliberate practice to improve their performance without harming any patients [6].
The successful application of VR in medical education requires careful planning and implementation. Through our experience launching VR-based clinical simulation sessions in hospitals such as the Sunnybrook Health Sciences Centre, the Hospital for Sick Children, and the Sunnybrook Canadian Simulation Centre, this tutorial aims to provide educators with a series of practical suggestions for designing and implementing VR-based medical education sessions (Textbox 1). Throughout this paper, we will outline the BUILD REALITY (begin, use, identify, leverage, define, recreate, educate, adapt, look, identify, test, amplify) framework and use our experience from the development and implementation of our VR environment as a case study to further reinforce our suggestions. The VR-based medical simulation environment we developed is (1) being used in the Sunnybrook Simulation Centre and (2) being tested in a clinical trial (Clinicaltrials.gov {"type":"clinical-trial","attrs":{"text":"NCT04451590","term_id":"NCT04451590"}}NCT04451590) to assess whether it can enhance the decision-making skills of medical trainees during an airway injury crisis scenario (Multimedia Appendix 1).
Before creating a new VR clinical environment, it is important to involve all stakeholders and conduct a needs assessment. The stakeholders that should be involved include the end users, human factor specialists, content experts, and software design technical experts. The team should conduct interviews, use focus groups, and make real-life observations to identify an unmet problem in the medical education system.
As shown in , there are certain factors to consider in a needs assessment that may promote creating a VR-based medical environment over another teaching modality. These factors include location, time, accessibility, assessment, personnel, software, diversity, and learning environment [4-6]. Compared to manikin simulation, VR simulation is not geographically constrained and allows for asynchronous learning. VR environments can be designed to be accessible to the user, especially for individuals with mobility constraints, and they require less intensive use of hospital and human resources than manikin simulation. Compared to other teaching modalities, the learning-by-doing nature and first-person perspective of VR allows for new forms of assessment and evaluation. The VR environment can easily be updated and changed as new medical guidelines are released and diversity can be built in through various avatars and virtual patients. Finally, the learning environment can be customized to replicate any environment (eg, an operating room or a trauma center), including simulated equipment and ergonomics.
Open in a separate windowIf the needs assessment identifies a gap requiring a standardized, accessible, or self-regulated solution, then VR is an up-and-coming technological solution [6]. In the past, VR environments have been created for procedure education support, anatomy training, and clinical decision-making. VR can be used to educate patients, medical students, residents, other health care providers, and interprofessional teams [7-10]. Before creating a VR environment, one should perform thorough market research to see if another laboratory or commercial entity has already created a VR environment that satisfies the educational requirements. If this is the case, the VR assets or environment can be shared and downloaded onto the VR platform used. If it is decided that a VR environment should be developed, budget support should be considered for both the technical and nontechnical expenses of the project.
As part of the needs assessment for our VR airway scenario, we collected feedback through focus groups from various program directors, nurses, medical learners, trauma physicians, and anesthesiologists. Additionally, we conducted clinical observations of manikin-based simulation sessions and real-life airway trauma cases to identify gaps that could be addressed through VR.
The objectives should be aligned with an education evaluation model, such as the Kirkpatrick model [11]. The Kirkpatrick model is used to evaluate the effectiveness of a learning program and allows for objective setting early in the development pipeline. For instance, with a VR-based simulation environment, the Kirkpatrick model objectives related to the anticipated reaction, learning, behavior, and results [12] should be set out during the design stage of the VR environment. With these objectives in mind, the team can work to select certain parameters, such as the type of VR headset and environment. The objectives should be aligned with the latest medical textbooks and reviewed with stakeholders and end users. In helping to formulate the objectives, one should involve an interprofessional group of educators—this ensures all professional perspectives can be drawn upon [13]. Based on the use case of the VR environment (eg, memorization or decision-making), the group should set objectives based on knowledge acquisition, application, and core decision-making steps that need to be conveyed.
For instance, for our airway crisis management scenario, we created objectives related to the content, technical skills, and nontechnical skills that needed to be conveyed (Multimedia Appendix 2).
Once the needs assessment and the objectives are set, the interprofessional team should determine the level of immersion, interactivity (passive vs active), and the modality required for the environment. It should be noted that immersion can include sound, eye tracking, VR controllers, and haptic feedback, among other features. Interactivity in VR is often on a spectrum where passive VR is similar to watching an engaging movie and active VR is when one can manipulate an environment, similar to our airway environment (Multimedia Appendix 1). Once these parameters are decided upon, the hardware can easily be selected. The options include a screen-based or a stand-alone VR headset ( ) [14,15].
Based on our airway crisis scenario needs assessment and objectives, we wanted an immersive and active environment that simulated a trauma bay. Therefore, we used a stand-alone VR headset with sound, eye tracking, and controllers to allow learners to make decisions and physically practice their clinical decision-making.
VR can simulate environments that enhance learning while also being interactive and immersive. To maximize the effectiveness of the VR environment, it should be built on sound learning theories, such as constructivism and self-regulated learning. For example, with constructivism, knowledge is constructed in a learning-by-doing fashion. Therefore, a VR-based simulation that allows the trainee to actively participate in the environment through navigation and manipulation is extremely beneficial [16].
An advantage of VR compared to manikin-based simulation is that it can be performed without access to a simulation center, which requires specialized personnel. VR is a modality that could provide a lower cost of learning where assessment and feedback processes can be preprogrammed into the VR environment and thus promote self-regulated learning [17]. This aspect ensures that the learner can go over key concepts at their own speed and practice as many times as needed [18]. The LOOP (learning theory, objectives, outcome, and output) framework is a design framework used for immersive VR environment development that is based on sound learning theory and objectives to create the VR output [19].
In our VR environment, the medical trainee goes through the core decision-making steps in an airway trauma to save a patient. While our scenario requires rapid decision-making, which presents a challenge for medical trainees, the trainee can go through the scenario as many times as needed. Each time, the algorithm provides feedback to promote self-regulated learning. Overall, we built the VR environment following self-regulated learning and constructivism learning theories.
Cocreation occurs when learners and educators work collaboratively with one another to create educational resources [20]. An interprofessional team must be established to use the objectives to create a suitable VR environment. This will include individuals previously involved in the needs assessment and additional software developers, animators, human factor specialists, medical education researchers, and clinicians [21]. Together, they will provide the software background, curriculum content, and educational design input needed to effectively achieve the project outcomes. Any team must clearly define research questions, identify roles and responsibilities, set attainable goals, and communicate frequently.
The interdisciplinary team should follow three steps: (1) Create an outline, program goal, and detailed flowchart for the VR program. This skeleton should then link key educational goals and objectives with the visual elements in VR. (2) Use the outline as a building block for the developers and animators to create the first prototype of the VR environment. They will create these assets themselves or purchase assets. A game engine such as Unity or Unreal should be used when bringing together the assets, 3D models, 2D graphic designs, video elements, and voices [22]. (3) Test the initial iterations meticulously and evaluate both the VR environment and its use by learners; this is important in the design process.
We brought together an interprofessional team for our VR airway scenario, including software developers, learners (first to third years of medical education), program directors, medical educators, and health care professionals. A flowchart for the VR airway scenario is provided in Multimedia Appendix 3.
Creating a new VR environment for the medical curriculum is a great opportunity to uphold the medical community’s commitment to inclusion, diversity, and equity. This can be done by creating patient and clinician avatars with diverse characteristics, such as age, height, weight, race, ethnicity, sex, gender, and health conditions. Since the VR environment can be repeated with ease, different patient or clinician avatars can be introduced in the medical trainees’ simulation curriculum. This opportunity for diversity is unique to VR when compared to traditional simulation-based medical education, where the purchased manikin is of the same sex and skin color for all medical trainees [23].
Additionally, VR allows the user to interact with the environment in multiple different ways. Users can teleport across the virtual room with a controller instead of walking, which is extremely beneficial for people who have physical disabilities. The room scale can be adjusted to eye height for individuals who need to be seated or are in a wheelchair [24]. These inherent accessibility elements should be introduced in the design of the VR environment to allow for increased utility.
In our case, the VR airway scenario included diverse avatars and various built-in features for accessibility needs. For instance, the medical trainee could use the controller to teleport across the trauma bay instead of walking, and they could move the virtual hospital bed up or down based on their height and reach (Multimedia Appendix 1).
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